Commercial Liability Application Name of Applicant and All Affiliated Companies Mailing Address Principal Location Any Foreign Operations? Yes No Give a complete description of the Applicant's Operations Annual Sales or Gross Receipts Payroll Number of Employees Years in Business Limit of Liability Requested Has Applicant previously carried Umbrella or Excess Coverage Yes No Has any insurer rejected, cancelled or refused renewal of any excess coverage? Yes No Indicate Number and Operating Radius of all Owned and/or Leased Vehicles Private Passenger Light Trucks 10,000 or less Trailers Other Is Applicant a Contract Hauler? Yes No Construction of Bldg is Date Built? Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 12345678910111213141516171819202122232425262728293031 Part Occupied by Applicant Describe Business of Tenant if applicable Applicant's exposure basis for policy rating Does applicant maintain a pool, Lake or Bathing Beach? Yes No Does Applicant or Tenant handle, use or store chemicals? Does Applicant have underground storage tanks on premises owned or leased? Yes No Describe Types of Work Performed Payroll Gross Receipts Describe work performed by Subcontractors Has Applicant performedwork for Public Utilities, Transportation or Goverment Entities? Briefly describe Applicant's largest contracts in past (5) years Does the Applicant ever agree orally or in writing to assume the liability of others? Yes No Give a complete description of products manufactured, sold, handled or distributed by the insured and attach Product brochure. Does applicant have employees covered under this jones act, federal railroad employees act or long shoreman's and harbor workers act? Does insured own, operated, maintain or use any aircraft, watercraft or railroad? Yes No Give annual expenditure and media used Losses paid or reserved insured or uninsured Additional Information or Remarks |Home| |Services| |Applications| |Auto Form| |Bonds Form| | Boat Insurance Form| |Commercial Form| |Disability Form| |Home Form| |Motorcycle Form| |Property Form| |Restaurant Form| |Renter Form| |Workers Comp Form| |Contact Us|